Management of patients brought in by ambulance to the emergency department: role of the Advanced Musculoskeletal Physiotherapist.

Objective The aim of the present study was to evaluate the role of the Advanced Musculoskeletal Physiotherapist (AMP) in managing patients brought in by ambulance to the emergency department (ED). Methods This study was a dual-centre observational study. Patients brought in by ambulance to two Melbourne hospitals over a 12-month period and seen by an AMP were compared with a matched group seen by other ED staff. Primary outcome measures were wait time and length of stay (LOS) in the ED. Results Data from 1441 patients within the Australasian Triage Scale (ATS) Categories 3-5 with musculoskeletal complaints were included in the analysis. Subgroup analysis of 825 patients aged ≤65 years demonstrated that for Category 4 (semi-urgent) patients, the median wait time to see the AMP was 9.5min (interquartile range (IQR) 3.25-18.00min) compared with 25min (IQR 10.00-56.00min) to see other ED staff (P ≤ 0.05). LOS analysis was undertaken on patients discharged home and demonstrated that there was a 1.20 greater probability (95% confidence interval 1.07-1.35) that ATS Category 4 patients managed by the AMP were discharged within the 4-hour public hospital target compared with patients managed by other ED staff: 87.04% (94/108) of patients managed by the AMPs met this standard compared with 72.35% (123/170) of patients managed by other ED staff (P=0.002). Conclusions Patients aged ≤65 years with musculoskeletal complaints brought in by ambulance to the ED and triaged to ATS Category 4 are likely to wait less time to be seen and are discharged home more quickly when managed by an AMP. This study has added to the evidence that AMPs improve patient flow in the ED, freeing up time for other ED staff to see higher-acuity, more complex patients. What is known about the topic? There is a growing body of evidence establishing that AMPs improve the flow of patients presenting with musculoskeletal conditions to the ED through reduced wait times and LOS and, at the same time, providing good-quality care and enhanced patient satisfaction. What does this paper add? Within their primary contact capacity, AMPs also manage patients who are brought in by ambulance presenting with musculoskeletal conditions. To the authors' knowledge, there is currently no available literature documenting the performance of AMPs in the management of this cohort of patients. What are the implications for practitioners? This study has added to the body of evidence that AMPs improve patient flow in the ED and illustrates that AMPs, by seeing patients brought in by ambulance, are able to have a positive impact on the pressures increasingly facing the Victorian Ambulance Service and emergency hospital care.

Advanced musculoskeletal physiotherapists are effective and safe in managing patients with acute low back pain presenting to emergency departments.

Objective The aim of this study was to compare emergency department (ED) key performance indicators for patients presenting with low back pain and seen by an advanced musculoskeletal physiotherapist (AMP) with those seen by other non-AMP clinicians (ED doctors and nurse practitioners). Methods A retrospective audit (October 2012-September 2013) was performed of data from three metropolitan public hospital EDs to compare patients with low back pain seen by AMP and non-AMP clinicians. Outcome measures included ED length of stay, ED wait time, admission rates and re-presentation to the ED. Results One thousand and eighty-nine patients with low back pain were seen during AMP service hours (360 in the AMP group, 729 in the non-AMP group). Patients seen by the AMP had a significantly shorter ED wait time (median 13 vs 32min; P<0.001) and ED length of stay (median 141 vs 175min; P<0.001). Significantly fewer patients seen by the AMP were admitted (P<0.001), and this difference remained after accounting for the difference in triage code between the groups. Conclusions Improved ED metrics were demonstrated in patients with low back pain when managed by an AMP compared with patients seen by doctors and nurse practitioners. What is known about the topic? There is a growing body of literature regarding the role of AMPs in the Australian healthcare system in providing clinical services for patients with musculoskeletal conditions, including settings such as the ED. AMPs have proven to be safe and cost-effective, achieving high patient satisfaction and improved patient outcomes. However, there is little to no information regarding their effect on ED metrics, such as ED length of stay, wait time and admission rates for patients presenting to the ED with low back pain. What does this paper add? This paper demonstrates improved ED metrics for patients presenting to the ED with low back pain when seen by an AMP compared with patients seen by doctors and nurse practitioners. The specific improved metrics for these patients were decreased admission rates, decreased ED length of stay and decreased wait time. What are the implications for clinicians? This paper provides evidence that the AMPs effectively discharge patients admitted to the ED in a timely manner, without evidence of increased readmissions, compared with their medical and nursing colleagues. Support for the role of the AMP within the ED setting is strengthened by these results.

A Model of Care for Osteoarthritis of the Hip and Knee: Development of a System-Wide Plan for the Health Sector in Victoria, Australia.

Osteoarthritis (OA) imposes a significant burden to the person, the health system and the community. Models of Care (MoCs) drive translation of evidence into policy and practice and provide a platform for health system reform. The Victorian MoC for OA of the hip and knee was developed following a best-practice framework, informed by best-evidence and iterative cross-sector consultation, including direct consumer consultation. Governance and external expert advisory committees consisting of local OA care champions facilitated the development and consultation processes. The MoC outlines key components of care, care that is not recommended, and suggests phased implementation strategies. This paper describes the MoC development process and lessons learned.

A diet and exercise program to improve clinical outcomes in patients with obstructive sleep apnea--a feasibility study.

STUDY OBJECTIVES: To assess the feasibility and efficacy of a novel 16-week exercise and diet program for important clinical outcomes in obstructive sleep apnea (OSA). METHODS: Cohort study assessing sleep disordered breathing, cardiovascular risk factors, and neurobehavioral function prior to and following completion of the 16-week program. The program used a proprietary very low energy diet (Optifast, Novartis), and subjects participated in a supervised exercise schedule, which included both aerobic and resistance training. Follow-up contact was made at 12 months after program exit. Consecutive patients with newly diagnosed sleep apnea were approached who had an apnea-hypopnea index (AHI) of 10 to 50, a body mass index (BMI) of greater than 30 kg/m2, no significant comorbidities, and able to exercise. RESULTS: All data are presented as mean [SD]. Of 21 patients with OSA who were approached, 12 middle-aged (42.3 [10.4] years old), obese (BMI 36.1 [4.3] kg/m2), and predominantly female (75%) subjects with mild to moderate OSA were enrolled (AHI 24.6 [12.0]). Weight loss was significant (12.3 [9.6] kg, p <0.001), and 5 of the 10 who completed the program were able to independently maintain good weight loss at 12 months. At the 16-week assessment, there was a small nonsignificant fall in the AHI. Six of the 10 subjects had a reduction in sleep disordered breathing, and the AHI was less than 10 in 3 patients. There were significant improvements in neurobehavioral and cardiometabolic outcomes. Snoring improved in most subjects, but the improvement was clinically important (a score of < 2) in only 7. CONCLUSIONS: A supportive diet and exercise program may be of benefit to obese patients with mild to moderate sleep apnea. The results of this feasibility study showed significant weight loss and improvement in clinically important neurobehavioral and cardiometabolic outcomes but no significant change in sleep disordered breathing. These promising preliminary results need confirmation with a larger randomized trial.

Physiotherapy-led triage clinic for low back pain.

The aims of this study were to evaluate a physiotherapy-led triage clinic (PLTC) and investigate general practitioner satisfaction with the PLTC. A retrospective cohort study was undertaken from January to December 2005 at a Melbourne tertiary teaching hospital. Outcomes assessed included waiting times to first appointment, patient attendance and surgery conversion rates. Outcomes were compared with the hospital 2002 benchmark data. GP satisfaction was evaluated by a survey. One-hundred and five new patients attended the PLTC clinic during the evaluation period. Patients waited 9 weeks for a PLTC appointment compared with 26 weeks for the general orthopaedic clinic and 23 weeks for the spinal orthopaedic clinic. Sixty-seven percent of the patients triaged in the PLTC were discharged from the orthopaedic outpatient department without requiring an orthopaedic surgeon consultation. Referring GPs were at least as satisfied with the management of their patients through the PLTC as with usual management in the general orthopaedic clinic. A PLTC can significantly reduce waiting times for orthopaedic outpatient appointments in a public hospital. Many patients can be managed by these experienced physiotherapists and their GPs, without the need for face-to-face contact with an orthopaedic surgeon. Pilot results indicated that GPs whose patients are managed in this PLTC were satisfied with this model for their patients with low back conditions.